Changing Childbirth: The Latin American Exampleby Robbie Davis-Floyd

Over the past two years, I have had the privilege of giving talks in 10 Latin American countries: Mexico, Costa Rica, Ecuador, Venezuela, Peru, Brazil, Paraguay, Uruguay, Chile and Argentina. Although Brazil has long been known as the “champion of cesareans,” several others are catching up to its high rates—the range in these countries is from 43.2% (Brazil) to 36% (Paraguay). These national rates reflect the average of low rates of cesareans in rural areas (such as the Brazilian Amazon) and much higher rates in urban areas, where cesarean rates range from 20–40% in the public sector (government-funded) hospitals and from 70–90% in private hospitals. I visited one hospital in Rio de Janeiro with a 99% cesarean rate—the joke there was “who is the one percent?”

21 Essential Ingredients to Bring About Birth Change

Early pioneers

A shared, named ideology

Existing models that work

Grassroots activists

Non-governmental organizations (NGOs)

Professional organizations

Midwives and other professionals educated in a humanistic model of care

The “good guys”: Humanistic and holistic obstetricians

Collaborative relationships across disciplines

An extensive body of literature and film of all kinds: Science, social science, philosophy, art, personal experience

Ongoing workshops and conferences

Involvement of international and local speakers and practitioners

Press coverage

Top-down professionals: International and national agencies, ministries

Regional networks

Multi-level links with related or semi-related networks, agencies, individuals, and organizations, from the local to the global

Inclusion of traditional midwives

Specific plans, goals, and benchmarks

Strong and effective leadership

Perseverance in the face of opposition and cooption

Younger people involved and learning

Nothing is as certain to start a social movement as a pendulum swing this far on the wrong side of the scientific evidence. As rates of prematurity, maternal infection and death rise because of so many unnecessary cesareans (see Betrán et al. 2006, Villar et al. 2007), more and more consumers and practitioners have become concerned and involved in trying to change this situation. Attention to the rising cesarean rates has also generated more awareness of the often callous treatment of women in many Latin American hospitals, where (depending on the hospital) they receive the worst of the technocratic model of birth—shaving, enemas, fasting, IVs, Pitocin, the lithotomy position, handstrapping, episiotomies, fundal pressure, manual removal of the placenta and unnecessary cesareans—all with no companionship or support.

In every country I visited, I have watched the social movement for the humanization of birth evolve and grow and have been consistently impressed with the energy and dedication of a new generation of birth activists in Latin America—a topic that could easily become a large research project. This article is simply a preliminary report of my personal observations on how the individuals and groups I encountered in these countries are changing childbirth. I hope it will serve as inspiration for further exploration and deeper understanding of the exciting work now being done in the Latin American world.

In brief, I have noted that at least 21 ingredients are necessary for creating a social movement that can effectively bring about birth change. (See sidebar.) I will address each of these in turn. This ordering is arbitrary—all are essential ingredients in creating an effective childbirth movement.

1. Early pioneers

Someone has to pave the way by breaking with traditional practice and trying something new. We can’t do studies on the outcomes of humanized births unless we have humanized births to study. Most practitioners cannot imagine what a truly humanistic birth looks like unless they see it in action, or at least through videos, articles and books. Many of you may remember the 1970s film Birth in the Squatting Position, made by Brazilian obstetrician Moysés Paciornik. It dealt with a series of beautiful births in which the most one saw of the obstetrician was his hand reaching out to lower the baby onto a soft towel and, later, that he turned to the side and cried at the beauty of the birth he had just witnessed. In those early days of the childbirth movement, many of us were amazed by the simplicity with which these women of various skin colors panted and pushed, the complete absence of interventions and the ecstasy on their faces as they reached down to scoop up their newborns.

Other pioneers of humanized birth in Brazil include Claudio Paciornik, who continues the work of his retired father; Hugo Sabatino, who also specialized in squatting birth; and Dr. Galba Araújo, who became the obstetrician in charge of the regional maternity hospital in Fortaleza in the state of Ceará, where he created an excellent system of support and transport for the traditional midwives in his region. He eventually developed so much respect for their practices that he brought hammocks and birthing chairs into his hospital. (This highly functional model of what anthropologist Brigitte Jordan calls “mutual accommodation” between traditional and professional practitioners vanished after Dr. Araujo died and was replaced by younger obstetricians who lacked the understanding of the normal physiology of birth that Dr. Araújo had gained from the traditional midwives he worked so hard to support.)

2. A shared, named ideology

Social movements develop most cohesively when they can crystallize around a shared ideology/goal with a consensually agreed-upon name. This has been a problem in the alternative birth movement in the English-speaking world—we have no agreed-upon name for what we are trying to achieve. Instead, we spiral around among terms such as “natural childbirth,” “prepared childbirth,” “conscious birthing,” “normal birth,” “respectful birth” and “the midwifery model of care,” among others. In dramatic contrast, the entire Spanish- and Portuguese-speaking world appears to agree on the term parto humanizado (humanized childbirth) as its ideological focus and principal goal, which is “the humanization of birth” as opposed to its de-humanization in contemporary obstetrical practice.

In my many talks and writings (see Davis-Floyd 2001b), I have warned about the limitations of this term—I have seen hospitals in Latin America declare themselves “humanized” simply because they suddenly decide to allow fathers to attend births. Two kinds of humanism exist: what I call superficial humanism, in which the room is pretty and the mother is treated kindly but the intervention rate does not decrease, and what I call deep humanism, in which the deep physiology of birth is honored. (Many US hospitals are superficially humanistic.) Deeply humanistic maternity hospitals may not have the prettiest rooms, but they do have birthing balls and upright chairs, they encourage women to eat and drink at will during labor, they encourage the mother to bring the companions of her choice, and they facilitate lots of moving around during labor and upright positions for birth. Midwives are usually the primary attendants at these births, while obstetricians tend to reserve themselves for their appropriate role, which is dealing with true pathology when it occurs. As Brazilian obstetrician Marcos Leite has often noted, “obstetricians should be the heroes of the hospital,” there to rescue when rescue is needed but leaving normal birth to the midwives. When the birth activists of Latin America speak of parto humanizado, this is the kind of deep humanism for which they are advocating. However, many of them are aware of how easily the term can be co-opted.

3. Existing models that work

One can find around Brazil pockets of excellence in birth that build on the work of the early pioneers. Extant models that work are essential for building a social movement around birth—theory must be shown in practice. One shining example is the practice of obstetrician Ricardo Herbert Jones and his wife, nurse-midwife Zeza Jones. They go to the woman’s home in early labor along with a doula and either attend her at home for the birth or go to the hospital if she prefers or if a cesarean is needed—giving a whole new meaning to the term “continuity of care.”

Another shining example of deep humanism in birth—I could cite dozens from around Latin America—is Hospital Avellaneda in Tucuman, Argentina. This public hospital attends 4000 births per year, with a cesarean rate of 15% (consistent with WHO guidelines), upright birthing chairs routinely used, midwives attending the majority of births and breastfeeding routinely supported and encouraged, even in the NICU. Obstetrician Mara Mohedano is the Director of Obstetrics and Perinatology for that hospital, and she advocates an ideology within which staff members can practice a true midwifery model of care. Such existing models that work clearly demonstrate the viability and sustainability of humanistic birth and can be replicated—indeed, other hospitals in Argentina are being redesigned around the Avellaneda model.

4. Grassroots activists

The involvement of grassroots activists in any social movement is critical. Real change must come from the bottom up and from the top down. In the world of birth, the most grassroots of grassroots activists tend to be childbirth educators, doulas, lactation consultants, nurses, midwives and the consumers of their services. (Doulas, for example, are still relatively unknown in Peru but are rapidly growing in number in Brazil, Paraguay and Uruguay.) These women open community centers where nascent mothers can go for birth preparation, breastfeeding support, day care and even cooking and sewing and other types of classes to help them gain needed skills (as I saw in Uruguay); and they form the bottom-up nucleus of the birth movement in their areas. Their involvement in the social movement is hands-on, direct, intimate, daily and long-term. Engaged consumers usually act as birth activists only during their childbearing years, yet their participation is essential. Grassroots activists know that consumers must be involved and show that they support the professionals and value and desire the services they provide and the ideology of birth and breastfeeding they advocate.

5. Nongovernmental organizations (NGOs)

The grassroots birth activists of Latin America often create NGOs to promote their cause in organized ways within their regions. In Paraguay, for example, my talks were sponsored by ParHuPar (Parto Humanizado Paraguay), which was founded by activist Pili Pena. According to its mission statement, “ParHuPar is a nonprofit NGO whose principal objective is the investigation, development and implementation of projects, programs and actions that promote prenatal and birth care according to the 10 Steps of the International MotherBaby Childbirth Initiative (IMBCI).” The IMBCI is based on the Coalition for Improving Maternity Services (CIMS) 10 Steps to Mother-Friendly Care, redesigned for international use.

Pili is a long-time participant in the CIMS International Committee (which has become the International MotherBaby Childbirth Organization [IMBCO]); she has reviewed various drafts of the Initiative and has adopted it as the standard around which to organize her work for the humanization of birth. Other Latin American NGOs are in the process of doing the same.

In fact, birth activists from Latin America like Pili and Flavia Previtali of Uruguay helped to encourage CIMS to create this international initiative. Most Latin American countries have NGOs like ParHuPar working for the humanization of birth; they keep the energy going in their respective regions and bring together under one umbrella various types of birth activists and professionals.

In Brazil, the early pioneers of humanized birth and those who continue their work formed an NGO in the 1990s called ReHuNa—Rede pela Humanização do Parto e Nascimento (Network for the Humanization of Birth). ReHuNa has sponsored many conferences and seminars, and ReHuNa leaders like Daphne Rattner and Marcos Leite have gained high-level positions in the Ministry of Health that have enabled them to create a national initiative to humanize birth (see below).

6. Professional organizations are essential for the viability of professions in any country.

Childbirth educators, lactation consultants, nurses, midwives and doulas all need their own national, regional and global professional organizations. The pioneer and immigrant midwives of the early centuries of the US and Canada often did not speak the same language or even know of each other’s existence, so they were not able to develop professional midwifery associations that could give them a unified voice—one reason physicians were able to almost eliminate midwifery in North America. In every Latin American country with sufficient numbers of midwives, professional midwifery organizations take care of the ongoing needs of the profession as well as participate in the larger social movement for the humanization of birth. The parteras of Argentina, the matronas of Chile, the enfermeiras-obstetras and obstetrizes of Brazil, and the obstetras of Peru all have national professional midwifery associations (I wish they could agree on a universal Spanish/Portuguese word for midwife—my suggestion is the simplest: partera/parteira). In Venezuela and Costa Rica professional midwifery does not officially exist; in Mexico so few professional midwives (parteras profesionales) exist that they have yet to form a viable national association, although they are well on their way. Midwives themselves need to control their professional standards and educational programs; national professional associations are essential to achieving self-control and midwifery autonomy.

Midwives are far more well-established in Latin America than doulas. Every time I speak in Latin America, I am asked, “What is a doula?” Yet there are doulas in most Latin American countries, even if only a few, and some of them have created professional organizations. These organizations sometimes compete or disagree—in Brazil for a time, the doulas of one large city wouldn’t work with the doulas of another. But as the number of new professionals grows, regional and stylistic differences often give way to an understanding of the need to unite for a larger cause, such as consistent doula trainings and a nationally recognized doula certification.

I would love to say that professional obstetric organizations form an essential part of the social movement to humanize birth in Latin America, but none of those that I have had contact with seem interested in making humanized birth a part of their organizational agenda. Of course, if a national obstetric organization dedicated itself and its educational programs to the humanization of birth, change would come swiftly. Unfortunately, to date such associations are the targets of pressure from all the other arenas I will mention, and not the catalysts for change that they could and ought to be. Yet any kind of permanent large-scale change will ultimately require their participation. Until and unless obstetrical education and practice systems change, the activists working to humanize birth will have to keep banging on the doors from the outside or working, as midwives, nurses and doulas often do, subtly and subversively from the inside.

7. Midwives and other practitioners educated in a humanistic model of care.

The term “midwifery model of care” is not well-known in Latin America; it doesn’t translate well into Spanish or Portuguese: el modelo de atencion parterista—it doesn’t ring. The essential focus, instead, is on education in deeply humanistic maternity care. Many Latin American midwives are educated in a highly technocratic approach to birth, but key midwifery leaders in various countries are working hard to change that, as are some obstetricians for their own profession (the hardest obstacle). One salient example in midwifery education reform is Dulce Rosa Gualda, the Director of Midwifery Education at the University of São Paulo. She recently created Brazil’s first direct entry midwifery program, in which a truly humanistic approach is being taught. In its first year, her program had more applicants than the entire nursing school! Another example can be found in Chile at the University of Concepción. There, educational director Yolanda Contreras and her colleagues have created an outstanding midwifery educational program centered around pre- and perinatal psychology and humanistic birth, for which Michel Odent and I serve as advisors.

In Mexico, the CASA School for Professional Midwifery in San Miguel stands as a shining example of excellence in midwifery education. Students are trained in a three-year program, gaining clinical experience in the CASA Hospital and with traditional midwives in rural areas, with whom they live and work for weeks at a time (see www.casa.org.mx). CASA’s rationale is the indisputable fact that traditional midwives in Mexico are retiring or dying without being able to train apprentices because so many young Mexican midwives want professional careers validated by the government cedula profesional (professional seal), which CASA offers. One of CASA’s main goals is to preserve and perpetuate traditional midwifery knowledge in a way that works and is governmentally acknowledged in the modern world (for more information, see Mills and Davis-Floyd, in press).

CASA is in the process of offering its model to other Mexican states; in the meantime, new schools of professional midwifery have been created in Oaxaca and Chiapas, and a school of traditional midwifery now exists in Cuernavaca, Morelos.

8. “The good guys”: humanistic and holistic obstetricians

Many individual Latin American obstetricians are practicing both inside and outside of hospitals in deeply humanistic ways. I first became aware of these “good guys” when I turned around after my keynote speech at a conference in Fortaleza in 2000 to find a group of good-looking men in their 30s and 40s holding armfuls of my books for me to sign. Amazed, I asked, “And who are you?” One of them responded, “We are the ‘good guys’—we are all obstetricians working to humanize birth. The ‘bad guys’ are the ones doing all the cesareans, and we are the ones working so hard against that to change birth in our hospitals and practices.”

Since then I have met dozens of “good guys” from all over Latin America and have collectively come to adore these obstetricians who are going against the technocultural grain, usually making far less money than their more technocratic colleagues and suffering a good deal of persecution in the process. They do it because they love women and babies, they love birth, and they understand the scientific evidence supporting normal physiological birth. In dramatic contrast to the resistance technocratic obstetricians feel at the idea of sitting or kneeling underneath a woman as she pushes, the good guys attend births in all positions, where women are mostly upright and often in the water.

I have found them in Monterrey, in Guadalajara, in Rio and Florianopolis and São Paulo, Vitoria, and Porto Alegre, in Caracas and Quito, in Santiago and Tucuman. Often isolated in their own cities, they are starting to show up at international conferences, hungry for information about how to keep growing on their paths and for contact with others who are doing the same. They want to talk to midwives and doulas; they want to participate in the international birth community; they want reinforcement and revitalization. Because they are essential to creating birth change, I am asking that whenever you meet a “good guy,” to please give him or her all the support you can! We can’t have humanistic birth without humanistic obstetricians, and these obstetricians have changed and are working to change their colleagues as well.

9. Collaborative relationships across disciplines

Collaboration is essential among all involved disciplines. Nurses and midwives, who are well-known to often not get along, constitute a salient example. This matters because nurses usually have the most power in hospital birth, simply because they are “there.” Nurses, who are usually very technocratically trained, can be as hard to convince as doctors to change childbirth. Yet no social movement to humanize birth can succeed without the involvement of nurses, at both individual and organizational levels. As is visible throughout Latin America, the autonomy of hospital-based midwives and their degree of failure or success is highly dependent on the nurses with whom they work.

10. An extensive body of literature and film of all kinds: Science, social science, philosophy, art, personal experience

Many books, such as those of Michel Odent, have already been translated and an increasing number of authors are creating the necessary literature base in both Spanish and Portuguese. The Cochrane database exists in Spanish and has been of tremendous assistance to Latin American epidemiologists (many of whom helped to create it), practitioners and activists. A tremendous amount of social science on birth exists in Latin America; unfortunately, most of it is in English. Many dedicated activists work hard to learn English to be able to read this literature, but much more translation is needed of key works in English about birth.

The art, personal experience, practice- and evidence-based literature in Spanish and Portuguese is very rich. Of particular note are Ricardo Herbert Jones’s Crónicas de un Obstetra Humanista (2006), published by Fundación Creavida (see also Jones, in press); Humanizando Nacimentos e Partos by Daphne Rattner and Belkis Trench (2005); a forthcoming edited collection led by Hugo Sabatino, Nacimiento Humanizado: Basado en Evidencias Científicas, which presents strong documentation of the benefits of humanized birth care; the film Born in Brazil produced by Kristine Hopkins and Cara Biasucci; Naolí Vinaver’s outstanding video Birth Day; humanistic obstetrician Paulo Batistuta’s gorgeous film Sagrado (Sacred) and his amazing collection on DVD of birth photos; Parto Normal ou Cesarea by Simone Grilo Diaz and Ana Cristina Duarte (2004) and many others too numerous to mention.

11. Ongoing workshops and conferences are essential to the growth and effectiveness of social movements because they educate, deepen understanding, keep the energy moving and focused, revitalize burned-out practitioners and catalyze growth and change.

Latin America is alive with such events. They range from the series of seminars an amazing group of women in Argentina called Fundación Creavida has been putting on for years, to the annual conferences of professional midwifery associations, to small workshops in birth facilitator centers, to huge cross-disciplinary conferences.

The instrumental role such conferences can play became clear to me at the First International Congress on the Humanization of Birth held in Fortaleza, Ceará, Brazil, in November 2000. The conference organizers, who included the Japanese International Cooperation Agency (JICA), did everything right in a networking sense, involving all relevant government and non-governmental organizations, from the National Ministry of Health to the local mayor. I was one of five international keynote speakers (the others were Marsden Wagner, Michel Odent, US midwife Ina May Gaskin, and British midwife and midwifery educator Lesley Page). We were told to expect around 600 participants, yet that first day we watched the auditorium fill until there was standing room only. The next day we arrived to find that the conference had been moved to a much larger auditorium that could accommodate the 2000 people who had arrived! We then realized that we were witnessing the official birth of the movement to humanize childbirth in Latin America.

Present at that conference were physicians, nurses, public health officials, midwives (both professional and traditional), doulas, childbirth educators, lactation consultants and government ministry officials. All had come in reaction to the out-of-control cesarean rate and the shockingly dehumanized conditions of birth in so many Latin American hospitals. The reason this congress captured so much attention was that the essential ingredients for creating a social movement around birth were already present in Brazil: early pioneers, grassroots activists, networks and NGOs, professional midwives, good guys, high ministry officials, plenty of existing small-scale models that work and strong and effective leadership. The long-term development of all these ingredients is the reason that Brazil has the most sophisticated social movement for the humanization of birth in all of Latin America. This conference sparked the evolution of many more.

To illustrate how one small series of talks and workshops can lead to the official creation of a social movement for the humanization of birth, I describe the recent work of Beltrán Lares Díaz of Venezuela. Beltrán is a humanistic obstetrician and birth activist following in the footsteps of Venezuelan pioneer Eva Gundberg, with whom he collaborates. He attends home and hospital births in Caracas with his wife Isabel, a doula. Like so many of the good guys, he travels to attend international conferences to get the support he needs. I met him at the Association for Prenatal & Perinatal Psychology and Health (APPPAH) conference in Los Angeles in 2006. Upon discovering that I would already be speaking in nearby Ecuador, he invited me to come to Caracas as well—this trip was only a month and a half away, but he trusted he could put something together by then. He jumped in his car and drove to the Ministry of Health, where he enlisted financial support from the official in charge of Reproductive Health, and to the two biggest maternity hospitals, the medical school and the anthropology department, where he introduced himself to those in charge and arranged for me to give talks, and to a birth facilitator center and a lactation center—in other words, he spanned the spectrum from top-down to grassroots. And I did give talks in all those places—two per day all over Caracas, and on the last night of my visit he and Isabel held a party in their home attended by people who had come to those talks, and at that party they collectively organized the first Venezuelan association for the humanization of birth and began to plan their first conference for next year.

Beltrán also took me to INAMujer, a government agency working for improvement in women’s living conditions and health. That agency, composed of many powerful feminist leaders, had just succeeded in getting a new law passed that specifically prohibits violence against women. A clause in the law addresses obstetrical violence; they were not sure how to go about implementing that clause. When Beltran and I presented them with a nascent social movement to humanize birth and a conference in the works, they agreed to help fund the conference as a means to achieving their own end—stopping obstetrical violence against women. Such is the power of networking, of engaged activism, of finding seemingly unrelated groups and binding them in a common cause.

The next week Barbara Harper gave two all-day seminars on gentle birth and waterbirth in another city in Venezuela. When she asked the hundred or so grassroots activists present how many of them would like to be midwives if professional midwifery existed in the country, almost all of them raised their hands. That began a national discussion on how to create midwifery schools and a midwifery profession in Venezuela.

12. Involving both international and local speakers

The involvement of local practitioners and others in conferences dedicated to the humanization of birth is critical—local people who are working for the humanization of birth need to be acknowledged for their efforts and contributions. They also need to meet and know each other and have a chance to resolve their (inevitable) personal differences so they can work together for the higher cause.

International speakers also are vital because they can present the scientific evidence from a global perspective, they can describe what is going on in other countries, and they help to form and coalesce the international birth community whose culture and beliefs will be fundamental to supporting movements in each country and region. (I have to note that it is great to be invited to speak in Latin America, not only to serve but also because of the extraordinary warmth and hospitality with which one is treated!)

One example of this appropriate inclusion of local and international speakers: The first Ecuadorian Congress on the Humanization of Birth was held in May 2007, organized by “good guy” obstetrician Diego Alarcón and his wife Lili, a doula. They run an existing model that works, a small private hospital called Clinica La Primavera in which they attend water births in their two gorgeous birthing suites complete with wood-paneled birthing tubs and candlelight. They brought together just the right combination of local practitioners and international speakers; attendance was about 250, the energy was high and this conference facilitated the coalescence of a national movement in Ecuador.

13. Press coverage

When I visited Uruguay, a series of articles about doulas had just come out in the local newspapers. Doulas are new news and so is humanized birth in these countries. The media love new stuff. (It’s not new in the US, where reporters usually don’t want to cover birth conferences unless some sort of maternal or fetal death is involved so they can report on the scandal.) In Latin America, every conference I’ve attended or solo talk I’ve given has received a great deal of press coverage, in part because the local activists have worked hard to cultivate relationships with reporters—newspaper, radio, television, Internet—to get their message out.

14. Top-down professionals: government agencies and ministries

In Chile, when Michel Odent and I were speaking at the conference Ser y Nacer (To Be and To Be Born), organized by Yolanda Contreras at the University of Concepción, the Ministry of Health official in charge of reproduction, Dr. René Castro, arranged for us to give talks on closed circuit TV for the staff of a number of maternity hospitals. He is proud of the 30 or so baby-friendly hospitals in Chile, is working toward certifying more and is extremely engaged in working with doctors and public health officials to humanize birth. Grassroots activists must find such supportive government officials and involve them in their events and efforts.

Inspired by the work of Galba de Araújo, the Brazilian Ministry of Health has created an award in his name that is given biannually to hospitals that do the most to humanize their care. In addition, from 2004–2007, the coordinators of the Women’s Health Technical Area of the Ministry of Health created a series of five-day “Seminars on Humanized Obstetric and Neonatal Care Based on Scientific Evidence,” which was given to key staff members of close to 500 maternity hospitals to educate them in the humanization of birth and to encourage and support them to change (see Rattner et al., in press). This kind of top-down initiative can make a difference because, unlike the US, Brazil actually has an organized health care system, coordinated and linked at national, regional, and local levels.

15. Regional networks

Just one example: The day after the huge conference in Fortaleza in 2000, birth activists from all over Latin America met to talk and ended up establishing Relacuhapan—an effective computer network through which one can contact just about any birth activist in any Latin American country and through which information is regularly spread, enabling disparate groups to coordinate their efforts and get word out quickly about planned developments and events (relacahupan.net/ingles.htm).

16. Multi-level links with related or semi-related networks, agencies, individuals and organizations, from the local to the global

The humanization of birth does not just involve birth—it includes prenatal and postpartum care, breastfeeding (the success of which is intimately linked to a woman’s treatment during birth), maternal education and health, nutrition, wellness, family planning, disease prevention and much more. International agencies such as WHO, UNICEF, UNFPA, JPHIEGO, CLAP (the Latin American Center for Perinatology) and many others have high stakes in humanizing birth and dedicated workers whose involvement is crucial. The same is true for related local organizations and agencies. In Latin America, I see increasing involvement of grassroots and professional activists with development officials, far too much to describe in this brief overview. Too many birth activists overspecialize in their particular interests and organizations; everyone needs to reach beyond such boundaries.

17. Involving traditional midwives

Traditional midwives are officially being phased out in Honduras, Nicaragua, El Salvador, Costa Rica and other Latin American countries. Most birth practitioners in Argentina, Chile and Venezuela, for example, say that no traditional midwives are left in their countries, but if you look hard, you will find them. In Guatemala, Bolivia and Mexico, traditional midwives still attend a significant percentage of births, especially in rural areas. They have their own associations and many of them realize that they must work to preserve their knowledge and practice. In Brazil, a national government initiative specifically includes (enlightened) training programs for the traditional midwives of the Amazon and other regions; in Mexico, all of the 70 or so professional midwives in the country work with and do all they can to support traditional midwives.

In Cuernavaca, Mexico, the traditional midwives I have personally studied (Davis-Floyd 2001, 2003) put on their own conference this past August, calling it “Science and Tradition on the Same Path.” It was a stunning achievement, given the limitations of their resources. When Brazilian good guy Marcos Leite and I gave talks at the biggest maternity hospital in Oaxaca right after the Cuernavaca conference, we were asked by the obstetrical residents who filled the auditorium, “How can we practice humanized birth? The cesarean rate in our hospital is 80%! We have no space to be able to do what you recommend. How can we even see a normal birth to learn what it is like?”

Our obvious response was: “You have all around you hundreds of traditional midwives who practice in highly humanized ways—and here is one in the audience!” We then introduced Doña Enriqueta Contreras, who stood up to huge applause and announced that anyone who wanted to see normal birth had only to contact her and she could put them in touch with any number of midwives who could accommodate them. It was a momentary spanning of a huge cultural divide—many more are needed. In many regions of Latin America, traditional midwives are practically the only alternative to a cesarean, and they are very aware of that fact. Culturally-aware birth humanists all over the continent are working hard to prevent the elimination of traditional midwives and to incorporate them into the health care system, as Dr. Galba de Araújo did decades ago in Brazil.

18. Specific plans, goals and benchmarks.

Knowing exactly what you are working for is essential. In Latin America, the broadly desired results include:

Ideological change: A paradigm shift

Practice change: Humanization of birth

Policy change: Humanized protocols and economic incentives

Legal and regulatory change around women’s rights

New laws have already been passed in Argentina and Brazil guaranteeing a woman’s right to be accompanied in birth, and many more such initiatives are underway. The NGOs and government officials are setting specific goals to be achieved by specific dates. Their goals are not always reached by that time, but setting them and holding regular reviews to mark progress are essential steps.

19. Strong and effective leadership.

In Latin America, many leaders have emerged. They share a generally humble attitude, and are always pointing out how their work is “a team effort.” Yet those who hold the clearest vision, are the most organized and are effective communicators rise to leadership, as they must for the movement to progress.

20. Long-term perseverance in the face of opposition and cooption.

All efforts that go against the technocultural grain will be opposed and, always, will face the penultimate challenge of co-option—that is, of apparent but not real change. Perseverance based on scientific evidence and ongoing commitment to develop models that really work constitute the only viable response.

21. Younger people learning and involved.

Indeed they are, all over Latin America!

Conclusion

I repeat, this is a prelimary report on my personal experience of the changing of childbirth in Latin America, based solely on my observations during my travels. I am inspired by the efforts of this new generation of Latin American birth activists, and believe that we all have much to learn from their efforts, failures, and increasing success.

Davis-Floyd, Robbie. 2001. “La Partera Profesional: Articulating Identity and Cultural Space for a New Kind of Midwife in Mexico,” in Daughters of Time: The Shifting Identities of Contemporary Midwives, special issue of Med Anthropol 20(2–3): 185–243. Also available at www.davis-floyd.com.

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